RFI Browser

Back  RFI # 507: Medicare allowed amount blanks

Formal vs. Informal Help Informal Formal

Submitter

chuck wilhelm

Description

Emdeon has encountered rejections from healthcare insurance carriers on COB claims when they did not contain the Medicare allowed amount in loop 2320 AMT*B6. The issue arises when services rendered are never paid by Medicare such as Lab service, which is not even included on the fee schedule. Some carriers will not accept a claim where the Medicare paid amount is equal to zero, but the Medicare allowed amount is not present. The allowed amount is not returned on the 835 from Medicare if the service is not covered. Since it is also not listed on the fee schedule there would be no amount to report back. In addition we feel to say allowed amount is equal to zero would be misleading to the submitter. We are requesting the X12 committee to clarify if and when it is appropriate to send a Medicare paid amount of zero without a Medicare allowed amount being present in the claim

Response

There is no requirement for the allowed amount. Therefore it is inappropriate for any receiver to require the allowed amount. The notes on the AMT segments are created for optional usage only.

Recommendation

The Allowed amount as determined by the provider is calculated using the payer paid amount coupled with the sum of the patient responsible CAS amounts. These are identified by CAS segments which use the PR Group code.
The Coordination of Benefits (COB) Payer Paid Amount + sum of patient responsible CAS amounts = the Allowed amount.
Submission 1/8/2007
Status Date 3/14/2007
Status F - Final
Primary References
Document 0040X096A1
Section3
Page366
Set ID837
Loop2320
Segment Position300
Segment IDAMT